Provider Demographics
NPI:1770923500
Name:WISE, JESSICA (LPN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:MCDERMOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:38 DOWNEY DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-6193
Mailing Address - Country:US
Mailing Address - Phone:315-806-2184
Mailing Address - Fax:
Practice Address - Street 1:38 DOWNEY DR
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-6193
Practice Address - Country:US
Practice Address - Phone:315-806-2184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277809164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse